The etiologic spectrum of constrictive pericarditis

Case report: Constrictive pericarditis after coronary artery perforation during percutaneous coronary intervention

A 77-year-old man underwent percutaneous coronary intervention (PCI) at the right coronary artery, which was complicated by coronary artery perforation (CAP). After prolonged balloon tamponade proximal to the CAP there was no more contrast extravasation, and the CAP was thought to have resolved. Computed tomography (CT) and echocardiography the following day did not find evidence of continued bleeding, and the patient was discharged. Echocardiograms and chest CT scans obtained one week and two months after PCI detected no remarkable interval change. The patient complained of progressive dyspnea and abdominal distension seven months after PCI however, and echocardiography found an increased amount of pericardial effusion and constrictive physiology. The patient underwent pericardiectomy due to congestive hepatopathy, and progressive dyspnea. The pericardium was thickened and adhesive, and a dark bloody effusion was found. Pathology was unremarkable except for thick fibrosis. After the operation the patient made full recovery, and is stable three years after surgery.

Constrictive pericarditis: rare but reversible cause of protein losing enteropathy

Constrictive pericarditis is uncommon in children. It results from scarring and consequent loss of the normal elasticity of the pericardial sac and is most commonly seen as a late sequelae of idiopathic or viral pericarditis. Here, we report a case of protein losing enteropathy as a complication of constrictive pericarditis in a 2-year-old child. Pericardial thickening was demonstrated by cardiac MRI and subsequent pericardiectomy led to remarkable improvement and resolution of protein losing enteropathy.

Constrictive pericarditis caused by pericardial metastasis from esophageal squamous cell carcinoma: a case report

Constrictive pericarditis is a rare condition characterized by clinical signs of right heart failure subsequent to the loss of pericardial compliance. We report a case of constrictive pericarditis due to pericardial metastasis in a patient with a history of esophageal squamous cell carcinoma that had a pathological complete response (pCR) to preoperative chemoradiotherapy. A 66-year-old woman was referred to our division for the treatment of advanced esophageal cancer. Video-assisted thoracoscopic surgery esophagectomy (VATSE) with 3-field lymphadenectomy was performed after neoadjuvant chemoradiotherapy (NAC-CRT). Pathological examination revealed no residual tumor, lymph node metastasis, lymphatic invasion, or vessel invasion. The histological treatment effect of the chemoradiotherapy was pathological complete response (pCR). Five months after surgery, the patient was admitted to a nearby hospital for the treatment of acute pericarditis. However, a month after admission, acute pericarditis progressed to constrictive pericarditis, and she was referred to our hospital for further management. Subsequently, urgent pericardiectomy was performed through a lower half sternotomy incision. After surgery, heart failure improved for a while but worsened again. The patient died 7 days after the surgery. Pathological examination of the resected pericardium revealed evidence of metastasis from squamous cell carcinoma of the esophagus. An autopsy revealed the spread of esophageal cancer to the bilateral pleura, right lung, pericardium, diaphragm, soft tissue surrounding the tracheal bifurcation, and bilateral hilar lymph nodes. Similarly, tumor cells were found in the lymphatic vessels of the pericardium and pleura. Even if pCR is achieved with NAC-CRT, as in our case, esophageal cancer may metastasize and present as constrictive pericarditis within a short period; therefore, careful patient follow-up is essential.

Pericardiectomy for constrictive pericarditis at a single Japanese center: 20 years of experience

OBJECTIVE

Constrictive pericarditis (CP) is a rare disease, and the diagnosis and surgical treatment of CP remain challenging. The aim of this study was to evaluate our Japanese single-center experience with isolated pericardiectomy for CP to elucidate the factors associated with improved outcomes.

METHODS

Over a 20-year period, 44 consecutive patients underwent isolated pericardiectomy at our institution. The cause of CP was: idiopathic (59%), postsurgical (32%), tuberculosis (7%), and postradiation (2%) of the patients. All patients were diagnosed with CP using multiple modalities, including echocardiography, cardiac catheterization, computed tomography, or magnetic resonance imaging (MRI). Median sternotomy was performed in 42 (95%) patients. Twenty-eight (68%) patients underwent radical pericardiectomy.

RESULTS

The postoperative diagnosis in all patients was CP. Among the multiple modalities, cardiac MRI had the greatest diagnostic sensitivity (97.2%). There were no operative or hospital deaths; late mortality occurred in seven (15.9%) patients in the series. Multivariable analysis showed that preoperative low LVEF was a risk factor for long-term mortality. Seven patients were readmitted for heart failure postoperatively. Multivariable analysis showed incomplete pericardiectomy and use of a preoperative inotrope were risk factors for readmission for heart failure.

CONCLUSIONS

The diagnosis using multimodality imaging for CP was effective in our institution and tagged cine MRI had the greatest sensitivity in diagnosing CP. Preoperative condition, including preoperative low LVEF or inotrope use, was correlated with long-term outcome after pericardiectomy. Pericardiectomy should be performed early and as radically as possible to prevent recurrent heart failure.

Cardiac magnetic resonance imaging in unclear cases of ventricular interdependence: a case series

BACKGROUND

Diagnosis of constrictive pericarditis requires demonstration of interventricular interdependence which can prove difficult even with invasive haemodynamics. Its treatment requires invasive surgical procedures prior to which diagnostic certainty is necessary. Cardiac magnetic resonance imaging (MRI) is an underutilized tool for identification of this pathology.

CASE SUMMARY

We present two cases of heart failure due to interventricular interdependence with inconclusive invasive haemodynamic. Prior to recommending invasive surgical treatment, confirmation of the diagnosis was required. This was achieved using cardiac MRI leading to pericardiectomy followed by clinical improvement.

DISCUSSION

These cases demonstrate the clinical utility, sensitivity, and specificity of cardiac MRI for ventricular interdependence.

Constrictive pericarditis: 21 years' experience and review of literature

To the best of our knowledge there are no publications about Tunisian experience in constrictive pericarditis (CP); the aim of this study was therefore to review our twenty-one years’ experience in terms of clinical and surgical outcomes and risk factors of death after pericardiectomy. An analytic bicentric and retrospective study carried out on 25 patients (20 male) with CP underwent pericardiectomy, collected over a 21-years period. The mean age was 40.46±16.74 years [7.5-72]. The commonest comorbid factor was tabagism (52%). The most common etiology was tuberculosis (n = 11, 44%). Dyspnea was the most common functional symptom (n = 21, 84%). Pericardiectomy was performed in all our patients within 2.9±3.19 months after confirmation of diagnosis. It was subtotal in 96% of cases. The commonest postoperative complications are pleural effusion (20%). Dyspnea was regressed within 1.8 months in 80% of cases and clinical signs of right heart failure within a mean duration of 1.62 months in 53% of cases. Perioperative mortality was 12% (3 deaths), late mortality was 4% (1 patient). Cardiopulmonary bypass, New York Heart Association (NYHA) over class II and right ventricular dysfunction are the prognostic factors of mortality (p = 0.001, 0.046, 0.019). Tuberculosis as etiology of CP had no impact on mortality. CP is a rare disease, with non-specific clinical signs. Pericardiectomy is effective with a significant improvement of the functional status of patients and favorable outcome at short and long term nevertheless hospital mortality is not negligible and depends on many factors.

Effusive-constrictive pericarditis in the spectrum of pericardial compressive syndromes

When pericardial fluid accumulates and exceed the reserve volume of the pericardium or when the pericardium becomes scarred and inelastic, one of three pericardial compressive syndromes may ensue, namely, cardiac tamponade (CT), characterised by the accumulation of pericardial fluid under pressure; constrictive pericarditis (CP), the result of scarring and loss of the normal elasticity of the pericardial sac; and effusive-constrictive pericarditis (ECP), characterised by the concurrence of a tense pericardial effusion and constriction of the heart by the visceral pericardium. Although relatively uncommon, prevalence estimates vary widely and depend on the nature of the cohorts studied, the methods used to diagnose ECP and the manner in which ECP is defined. Most cases of ECP are idiopathic, reflecting the frequency of idiopathic pericardial disease in general, and other causes include radiation, malignancy, chemotherapy, infection and postsurgical/iatrogenic pericardial disease. The diagnosis of ECP often becomes apparent when pericardiocentesis fails to decrease the right atrial pressure by 50% or to a level below 10 mm Hg. Important non-invasive diagnostic modalities include echocardiography, cardiac magnetic resonance and, to a lesser extent, cardiac CT. In cases with clear evidence of pericardial inflammation, a trial of an anti-inflammatory regimen is warranted. A complete pericardiectomy should be reserved for refractory symptoms or clinical evidence of chronic CP.

Pericardectomy after pericarditis constrictiva led to onset of transplant kidney function after 98 days of anuric kidney graft: a case report

BACKGROUND

Constrictive pericarditis is easily overlooked and can lead to severe problems in hemodynamics and end-organ perfusion, in our patient leading to 98 days of anuria after living kidney transplantation. This was completely reversible after pericardectomy.

CASE PRESENTATION

A 43-year-old female caucasian patient received a living kidney donation from her mother. She had developed end-stage renal disease 2 years prior due to nephrotic syndrome linked to graft-versus-host disease after allogenic stem-cell transplantation for aplastic anemia. The graft showed insufficient function already in the early postoperative phase. Dialysis was paused after surgery, but the patient developed hypervolemia with ascites and edema in the lower extremities. Doppler ultrasonography showed scarce perfusion, with intrarenal arterial waveforms without end-diastolic flow. The venous perfusion profiles showed pulsatile retrograde flow. There was no identifiable reason for a primary vascular perfusion problem on ultrasonography or transplant kidney angiography. Kidney transplant biopsy revealed no rejection but extensive acute tubular necrosis. Three weeks after transplantation, the patient developed an acute anuric graft failure caused by severe cardiac decompensation. Echocardiography revealed a previously unnoticed constrictive pericarditis, which could be confirmed in a cardio computed tomography scan. The constrictive pericarditis had not been apparent on previous x-rays, computed tomography scans, or echocardiographies, including those for transplantation evaluation. Conservative management of the constrictive pericarditis was not successful and the graft remained anuric. Eventually, the patient underwent pericardectomy 16 weeks after kidney transplantation. Shortly after surgery, the graft started urine production again, which significantly increased within a few days. The clearance improved and 2 weeks later, the patient was free from dialysis.

CONCLUSIONS

This case illustrates that special attention should be given to the pericardium during transplant evaluation, especially for patients who previously underwent stem-cell transplantations, chemotherapy or radiation.

Recognizing Radiation Therapy-related Complications in the Chest

Radiation therapy is one of the cornerstones for the treatment of thoracic malignancies. Although advances in radiation therapy technology have improved the delivery of radiation considerably, adverse effects are still common. Postirradiation changes affect the organ or tissue treated and the neighboring structures. Advances in external-beam radiation delivery techniques and how these techniques affect the expected thoracic radiation-induced changes are described. In addition, how to distinguish these expected changes from complications such as infection and radiation-induced malignancy, and identify treatment failure, that is, local tumor recurrence, is reviewed. ^©RSNA, 2019.

Breaking hearts and taking names: A case of sarcoidosis related effusive-constrictive pericarditis

INTRODUCTION

Pericardial involvement of sarcoidosis is a rare cause for acute heart failure, and usually occurs as a result of the development of a pericardial effusion leading to cardiac tamponade. Even rarer still, is the manifestation of constrictive pericarditis. We report a case of sarcoidosis with lung, pleural, and pericardial involvement with effusive-constrictive pericarditis leading to cardiac tamponade.

CASE PRESENTATION

A 34-year-old Caucasian man presented for evaluation of a history of worsening exertional dyspnea, edema, and weight loss. A high-resolution chest computed tomography showed diffuse pulmonary nodules with upper lobe predominance and in a perilymphatic distribution; large right pleural effusion; and large pericardial effusion with pericardial thickening. A transthoracic echocardiogram demonstrated early tamponade physiology for which a pericardial drain was placed. After removal of the drain he developed cardiogenic shock from cardiac tamponade attributed to the reaccumulation of a pericardial effusion and urgent pericardial window was performed. Serial echocardiography was concerning for organization and localization of the pericardial fluid. Cardiac magnetic resonance imaging demonstrated a significant reduction in pericardial slippage between the parietal and visceral layers around the heart collectively suggestive of constrictive pericarditis. Confirmation of effusive-constrictive pericarditis was noted on right heart catheterization. He then underwent pericardiectomy, which on histopathologic evaluation demonstrated non-necrotizing granulomas, thus confirming pericardial involvement of sarcoidosis.

CONCLUSIONS

We report a case demonstrating unique manifestations of sarcoidosis; effusive-constrictive pericarditis presenting with acute congestive heart failure.

[Management of pericarditis and pericardial effusion, constrictive and effusive-constrictive pericarditis]

This CME review takes stock of the progress in the etiology, pathophysiology, diagnostics and treatment of pericarditis and pericardial effusion brought about by the publication of the 2nd European Society of Cardiology (ESC) guidelines on the management of pericardial diseases in 2015. It also emphasizes special forms, which have received less attention in the past, such as therapy-refractory (incessant), effusive-constrictive and constrictive pericarditis and the treatment of acute and recurrent pericarditis with colchicine. After the diagnosis of pericarditis with or without effusion has been made, the first step is to clarify its etiology, which affects the clinical symptoms, course, treatment and the prognosis. In this aspect the requirements of the guidelines and the reality of an etiological classification of pericardial diseases diverge in many cases. The diagnosis of "idiopathic" acute or recurrent pericarditis is still much too often the result of insufficient efforts to find the cause. Too often only malignant and bacterial forms are excluded. If the etiology is known local intrapericardial treatment with the already inserted pigtail catheter from the diagnostic pericardial puncture can be carried out with few systemic side effects. The 2015 ESC guidelines recommend colchicine as first line treatment in all forms of pericarditis except for neoplastic pericardial effusion. It accelerates healing and reduces the frequency of recurrence of pericarditis but cannot eliminate recurrence completely. The best treatment and prevention of recurrence is the eradication of the underlying etiological cause.

The waffle procedure as treatment of a first episode of right heart failure: a case report

Background

Constrictive pericarditis is a rare condition which is characterized by pericardial layers thickening and it may not be relieved by conventional medical or surgical therapies. Some patients could profit from specific surgical techniques such as the waffle procedure which removes epicardial tissue strips of the visceral layer of the pericardium. It alleviates diastolic dysfunction, since it is known that the constrictive physiology observed in constrictive pericarditis depends mainly on the visceral layer.

Case summary

We describe the case of a 59-year-old male complaining of predominantly right heart failure symptoms. Initially, a transthoracic echocardiogram showed pericardial effusion with several fibrous tracts and a constrictive pattern. The work-up was completed with thoracic computed tomography and right heart catheterization along with several microbiological, serological and immunological tests. The final diagnosis was idiopathic constrictive pericarditis. The clinical course was unfavourable, and the patient was referred for prompt surgical treatment using a technique called the waffle procedure. Subsequently, the patient has remained asymptomatic.

Discussion

Constrictive pericarditis combines features of both constriction and tamponade. Some patients may present an unfavourable clinical course with conventional therapeutic approaches. They could benefit from the waffle procedure which allows an improvement in diastolic and, subsequently, in systolic function.

Constrictive Pericarditis as a Long-term Undetermined Etiology of Ascites and Edema

Constrictive pericarditis (CP) is defined as impedance to diastolic filling caused by a fibrotic pericardium. The diagnosis of CP is a clinical challenge and requires a high index of clinical suspicion. The signs and symptoms of CP include fatigue, edema, ascites, and liver dysfunction. These can be mistakenly diagnosed as primary liver disease. We present the case of a 69-year-old woman with a 7-year history of leg edema and a 2-year history of ascites who was initially diagnosed with cryptogenic liver cirrhosis and was finally diagnosed with CP.

Liver chemistry abnormalities and leg oedema in rheumatoid arthritis

A 66-year-old man with seronegative, erosive rheumatoid arthritis for 12 years presented with malaise, elevated alkaline phosphatase and gamma-glutamyl transferase, and leg oedema. He subsequently developed ascites. No liver pathology was found, but cardiac analysis including right heart catheterisation revealed constrictive pericarditis. Rheumatoid constrictive pericarditis is a rare condition, but, despite current effective treatment for rheumatoid arthritis, still occurs. Diagnostic delay is frequent. Although mortality of the intervention is high, pericardiectomy is needed for most patients.

Clinical features, management and outcome of patients with constrictive pericarditis - Experience from a third world country

Objectives

To study the clinical features, management and outcome of patients with constrictive pericarditis, at a tertiary care hospital of Pakistan.

Design

Descriptive study.

Material & method

All consecutive patients with the final diagnosis of constrictive pericarditis, admitted at Aga Khan University Hospital Karachi, during the year 2005 to 2015 were included in the study.

Results

A total of 21 patients were diagnosed and managed as constrictive pericarditis during the above mentioned period. Mean age was 39 + 19.9 years. There was a male preponderance with a male to female ratio of 2.5:1.The most common clinical features were those of right heart failure. Only 2 (9.5%) patients showed pericardial calcification on X-ray chest. Dilated atria and septal bounce were the most common echo features present in 15 (71.4%). MRI/CT was done in only 11 patients, of which eight showed increased pericardial thickness. Three had normal pericardial thickness on MRI/CT but were proved to have constriction surgically. Cardiac catheterization was done in nine patients only. Elevated filling pressures and square root sign were the most common findings, present in all (100%). Pericardiectomy was performed in 12 (57%) patients. Five more patients were advised surgery but two died before the surgery and three were taken to other hospitals as they wanted to explore other options beside surgery. Pericardial tissue histopathology was available in only 11 patients. It revealed tuberculosis in three cases, while in 8 cases it was nonspecific. Six patients died with an overall mortality of 28.6%. Five patients died during hospitalization, four without surgery and one after the surgery. One patient died during follow up (was considered unfit for the surgery). Mean follow up duration was 7.3 + 9.3 months. No death occurred on follow up in surgically treated patients.

Conclusion

Features of right heart failure is the most common mode of presentation of CP. The most probable etiology in this part of the world is tuberculosis, although difficult to prove on histopathology. Pericardiectomy is the usual recommended treatment due to advanced disease at the time of presentation.

Importance of Clinical and Laboratory Findings in the Diagnosis and Surgical Prognosis of Patients with Constrictive Pericarditis

BACKGROUND

International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce.

OBJECTIVE

To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy.

METHODS

Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant.

RESULTS

We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension >55 mm Hg, and atrial fibrillation.

CONCLUSIONS

Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death.

Effusive-Constrictive Pericarditis After Pericardiocentesis: Incidence, Associated Findings, and Natural History

OBJECTIVES

This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis.

BACKGROUND

ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler.

METHODS

A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared.

RESULTS

ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms.

CONCLUSIONS

In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.

Effect of Right Heart Systolic Function on Outcomes in Patients with Constrictive Pericarditis Undergoing Pericardiectomy

Background:

To determine the influence of right ventricular function in patients with constrictive pericarditis (CP) undergoing surgery and to compare the outcomes of patients who received surgery with those managed medically.

Methods:

Patients with the diagnosis of CP and healthy volunteers were recruited from January 2006 to November 2011. Patients with CP chose to either receive pericardiectomy or medical management. Echocardiographic measurements were performed to evaluate heart function, and survival was recorded.

Results:

A total of 58 patients with CP (36 received pericardiectomy, 22 managed medically), and 43 healthy volunteers were included. CP patients who received surgery had a higher survival rate than those managed medically (P = 0.003), and higher survival was also seen in the subgroup of CP patients with severely impaired right systolic function. Albumin level, left ventricular end-diastolic dimension, and tricuspid regurgitation velocity were associated with survival in CP patients who received surgery.

Conclusions:

Preoperative right heart function does not affect surgical outcomes. Patients with severely impaired preoperative right systolic function obtain a greater survival advantage with surgery than with medical treatment.

Redefining Effusive-Constrictive Pericarditis with Echocardiography

Background

Effusive-constrictive pericarditis (ECP) is traditionally diagnosed by using the expensive and invasive technique of direct pressure measurements in the pericardial space and the right atrium. The aim of this study was to assess the diagnostic role of echocardiography in tuberculous ECP.

Methods

Intrapericardial and right atrial pressures were measured pre- and post-pericardiocentesis, and right ventricular and left ventricular pressures were measured post-pericardiocentesis in patients with tuberculous pericardial effusions. Echocardiography was performed post-pericardiocentesis. Traditional, pressure-based diagnostic criteria were compared with post-pericardiocentesis systolic discordance and echocardiographic evidence of constriction.

Results

Thirty-two patients with tuberculous pericardial disease were included. Sixteen had ventricular discordance (invasively measured), 16 had ECP as measured by intrapericardial and right atrial invasive pressure measurements and 17 had ECP determined echocardiographically. The sensitivity and specificity of pressure-guided measurements (compared with discordance) for the diagnosis of ECP were both 56%. The positive and negative predictive values were both 56%. The sensitivity of echocardiography (compared with discordance) for the diagnosis of ECP was 81% and the specificity 75%, while the positive and the negative predictive values were 76% and 80%, respectively.

Conclusion

Echocardiography shows a better diagnostic performance than invasive, pressure-based measurements for the diagnosis of ECP when both these techniques are compared with the gold standard of invasively measured systolic discordance.

Radical Pericardiectomy for Chronic Constrictive Pericarditis

A retrospective analysis was undertaken in 79 patients who underwent pericardiectomy for chronic constrictive pericarditis from January 1985 to February 1999. Most operations (77) were carried out with cardiopulmonary bypass, with subtotal pericardiectomy in 75 patients, and concomitant operations in 25. Postoperative complications occurred in 8 patients: cerebrovascular accident in 2, renal insufficiency in 5, bleeding in 2, low output syndrome in 4, and respiratory insufficiency in 2. The operative mortality was 5%; causes of death were cardiac-related in all cases. Actuarial survival at 1, 5, and 10 years was 89.9% ± 3.4%, 74.9% ± 5.7%, and 55.4% ± 13.5%, respectively. Regression analysis was performed using 53 clinical variables. Female gender, renal insufficiency, concomitant coronary artery bypass grafting, and preoperative right ventricular end-diastolic pressure > 20 mm Hg were found to be predictors of poor survival. At follow-up, improved functional status was noted in 88% of patients. Subtotal pericardiectomy can be performed on cardiopulmonary bypass with low mortality and good long-term survival.

Long-term outcomes of pericardiectomy for constrictive pericarditis

Background

Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. The purpose of this study was to evaluate the long-term outcomes following treatment of constrictive pericarditis by pericardiectomy.

Methods

Between September 1992 and May 2014, 47 patients who underwent pericardiectomy for constrictive pericarditis were retrospectively examined. Demographic, pre-, intra- and postoperative data and long-term outcomes were analyzed.

Results

Thirty of the patients were male, the mean age was 45.8 ± 16.7. Aetiology of constrictive pericarditis was tuberculosis in 22 (46.8 %) patients, idiopathic in 15 (31.9 %), malignancy in 3 (6.4 %), prior cardiac surgery in 2 (4.3 %), non-tuberculosis bacterial infections in 2 (4.3 %), radiotherapy in 1 (2.1 %), uraemia in 1 (2.1 %) and post-traumatic in 1 (2.1 %). The surgical approach was achieved via a median sternotomy in all patients except only 1 patient. The mean operative time was 156.4 ± 45.7 min. Improvement in functional status in 80 % of patients’ at least one New York Heart Association (NYHA) functional class was observed. In-hospital mortality rate was 2.1 % (1 of 47 patients). The cause of death was pneumonia leading to progressive respiratory failure. The late mortality rate was 23.4 % (11 of 47 patients). The mean follow-up time was 61.2 ± 66 months. The actuarial survival rates were 91 %, 85 % and 81 % at 1, 5 and 10 years, respectively. Recurrence requiring a repeat pericardiectomy was developed in no patient during follow-up.

Conclusion

Pericardiectomy is associated with high morbidity and mortality rates. Cases with neoplastic diseases, diminished cardiac output, cases in need of reoperation are expected to have high mortality rates and less chance of functional recovery.

Eggshell calcification of the heart in constrictive pericarditis

Constrictive pericarditis (CP) is an inflammatory disease of pericardium. Pericardial calcification in X-ray provides a clue for the diagnosis of CP. An extensive “eggshell” type of calcification is rarely seen in CP. We hereby report a case of CP with eggshell calcification of pericardium, encircling whole of the heart. A need for multimodality imaging and hemodynamic assessment followed by surgical pericardiectomy is discussed.

Atrial flutter ablation in a case of diuretic resistant constrictive pericarditis

We present a 66 year old gentleman with constrictive pericarditis and persistent atrial flutter. Initial management with oral loop diuretics was successful until he developed persistent atrial flutter. Once in atrial flutter the patient developed progressive signs of right heart failure resistant to high dose intravenous loop diuretics. He was referred to a tertiary electrophysiology service where he underwent successful isthmus catheter ablation and reverted to sinus rhythm. His responsiveness to diuretics improved immediately. His symptoms improved and he was discharged 48 h later on oral diuretics. He remains well one month after discharge. This is the first reported case of symptomatic improvement in a patient with constrictive pericarditis and persistent atrial flutter with targeted treatment of the dysrhythmia. This offers a possible short-term palliation option in a group of patients where definitive surgical management carries too high a risk.

Radiation-induced heart disease: pathologic abnormalities and putative mechanisms

Breast cancer is a common diagnosis in women. Breast radiation has become critical in managing patients who receive breast conserving surgery, or have certain high-risk features after mastectomy. Most patients have an excellent prognosis, therefore understanding the late effects of radiation to the chest is important. Radiation-induced heart disease (RIHD) comprises a spectrum of cardiac pathology including myocardial fibrosis and cardiomyopathy, coronary artery disease, valvular disease, pericardial disease, and arrhythmias. Tissue fibrosis is a common mediator in RIHD. Multiple pathways converge with both acute and chronic cellular, molecular, and genetic changes to result in fibrosis. In this article, we review the pathophysiology of cardiac disease related to radiation therapy to the chest. Our understanding of these mechanisms has improved substantially, but much work remains to further refine radiation delivery techniques and develop therapeutics to battle late effects of radiation.

[Unilateral transudative pleural effusion and constritive pericarditis]

INTRODUCTION

Constrictive pericarditis is associated with thickening, fibrosis or inflammation of the pericardium which can lead to signs of right ventricle dysfunction. It is usually a chronic process which can present in a variety of ways. We present two cases of constrictive pericarditis discovered during the investigation of a left-sided pleural effusion.

OBSERVATION

The cases represent two sorts of constrictive pericarditis, chronic and due to pericardial effusions. Their common feature was an increase in dyspnoea and a new pleural effusion on the left side. Their difference lies in the presence of a thickened calcified pericardium in one case and the presence of a pericardial effusion in the other. In both cases, non-invasive investigation failed to diagnose any cardiac disease. The presence of constrictive pericarditis was confirmed by right heart catheterization. Treatment by subtotal pericardectomy was effective.

CONCLUSION

The thoracic manifestations of constrictive pericarditis are most commonly recurring bilateral pleural effusions. The mode of presentation may be an exudative, or transudative effusion. Unilateral pleural involvement, fibrosis, chylothorax or tumour like presentations may occur. A diagnosis of constrictive pericarditis should be considered in these clinical contexts and an examination of the pericardium performed. Cardiac catheterization can help in the differential diagnosis.

Cardiac sarcoidosis presenting as constrictive pericarditis

In patients with cardiac sarcoidosis, the sarcoid granulomas usually involve the myocardium or endocardium. The disease typically presents as heart failure with ventricular arrhythmias, conduction disturbances, or both. Constrictive pericarditis has rarely been described in patients with sarcoidosis: we found only 2 reports of this association. We report the case of a 57-year-old man who presented with clinical and hemodynamic features of constrictive pericarditis, of unclear cause. He was admitted for treatment of recurrent pleural effusion. After a complicated hospital course, he underwent pericardiectomy. His clinical and hemodynamic conditions improved substantially, and he was discharged from the hospital in good condition. The pathologic findings, the patient's clinical course, and his response to pericardiectomy led to our diagnosis of cardiac sarcoidosis presenting as constrictive pericarditis. In addition to the patient's case, we discuss the nature and diagnostic challenges of cardiac sarcoidosis. Increased awareness of this disease is necessary for its early detection, appropriate management, and potential cure.

Biventricular Failure due to Stress Cardiomyopathy after Pericardiectomy for Constrictive Pericarditis

Importance. Constrictive pericarditis is a rare clinical entity that frequently necessitates surgical intervention. Here we present a case of biventricular failure due to stress cardiomyopathy after pericardiectomy. This is an extremely rare complication that is not well described and does not have a definitive mechanism. Observations. A 40-year-old Ecuadorian woman who was found to have constrictive pericarditis due to Mycobacterium tuberculosis infection was referred to our institution. The presence of constrictive pericarditis was confirmed by echocardiography, computed tomography, magnetic resonance imaging, and cardiac catheterization. Following pericardiectomy, the patient developed biventricular failure consistent with stress cardiomyopathy (Takotsubo cardiomyopathy), based on the echocardiographic assessment of the ventricles, which demonstrated an akinetic apex and hyperactive base in both ventricles, the absence of significant epicardial coronary atherosclerosis, and prompt normalization of the cardiac function after intensive medical therapy. Conclusions and Relevance. Biventricular failure in the form of stress cardiomyopathy after pericardiectomy in the manner presented here has not been previously described in the literature. While postulations as to the cause of single ventricle dysfunction have been described, the exact mechanism is unclear and current theories do not explain the clinical features in this case of stress cardiomyopathy after pericardiectomy.

Cardiovascular complications of radiotherapy

Chest radiotherapy is routinely used to treat malignancies such as Hodgkin disease and breast cancer but is commonly associated with a variety of cardiovascular complications involving the pericardium, myocardium, valves, coronary arteries, and conduction system. Cardiovascular complications are related to the total dose of radiation and the fractionation of the dose. They are usually progressive, portend poor prognosis, and are often refractory to treatment after significant radiation exposure. The mechanism of injury is multifactorial and likely involves endothelial damage of the microvasculature and coronary arteries and liberation of multiple inflammatory and profibrotic cytokines. In conclusion, routine follow-up with a cardiologist, which might include screening for valvular disease with echocardiography and coronary artery disease with computed tomography angiography or coronary artery calcium scoring, should be considered in patients with a history of chest radiotherapy.

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

Incidental Cardiac Findings on Thoracic Imaging

The cardiac structures are well seen on nongated thoracic computed tomography studies in the investigation and follow-up of cardiopulmonary disease. A wide variety of findings can be incidentally picked up on careful evaluation of the pericardium, cardiac chambers, valves, and great vessels. Some of these findings may represent benign variants, whereas others may have more profound clinical importance. Furthermore, the expansion of interventional and surgical practice has led to the development and placement of new cardiac stents, implantable pacemaker devices, and prosthetic valves with which the practicing radiologist should be familiar. We present a collection of common incidental cardiac findings that can be readily identified on thoracic computed tomography studies and briefly discuss their clinical relevance.

MR, CT, and PET imaging in pericardial disease

Although echocardiography remains the standard diagnostic tool for identifying pericardial diseases, procedures with better delineation of morphology and heart function are often required. The pericardium consists of an inner visceral (epicardium) and outer parietal layer (pericardium), which constitute for the pericardial cavity. Pericardial effusion can occur as transudate, exudate, pyopneumopericardium, or hemopericardium. Potential causes are inflammatory processes, that is, pericarditis due to autoimmune or infective reasons, neoplasms, irradiation, or systemic disorders, chronic renal failure, endocrine, or metabolic diseases. Pericardial fat can mimic pericardial effusion. Using various image-acquisition sequences, MRI allows identifying and separating fluid and solid structures. Fast spin-echo T1-weighted sequences with black-blood preparation are favourably used for morphological evaluation. Fast spin-echo T2-weighted sequences, particularly with fat saturation, and short-tau inversion-recovery sequences are useful to visualize oedema and inflammation. For further tissue characterization, delayed inversion-recovery imaging is used. Therefore, image acquisition is performed at 5-20 min subsequent to contrast agent administration, the so-called technique of late gadolinium enhancement. Ventricular volumes and myocardial mass can be assessed accurately by steady-state free-precession sequences, which is required to measure cardiac function and ventricular wall stress. Constrictive pericarditis usually results from chronic inflammatory processes leading to increased stiffness, which impedes the slippage of both pericardial layers and thereby the normal cardiac filling. CT imaging can favourably assess pericardial calcification. Thus, MR and CT imaging allow a comprehensive delineation of the pericardium. Superior to echocardiography, both methods provide a larger field of view and depiction of the complete chest including abnormalities of the surrounding mediastinum and lungs. PET provides unique information on the in vivo metabolism of 18-fluorodeoxyglucose that can be superimposed on CT findings and is useful for identifying inflammatory processes or masses, for example neoplasms. These imaging techniques provide advanced information of anatomy and cardiac function to optimize the pericardial access, for example by the AttachLifter system, for diagnosis and treatment.

Surgical management of effusive constrictive pericarditis

Background

The surgical approach for effusive constrictive pericarditis (ECP) has not been extensively studied. We present our institution’s early and long-term results of pericardiectomy in our cohort of patients with ECP.

Methods

Diagnosis was made primarily by echocardiography. Right heart catheterisation was performed in eight patients. Pre-operatively, 10 patients had undergone at least one previous attempt at therapeutic pericardiocentesis. Pericardiectomy was performed where appropriate (thickened or inflamed).

Results

Of our 12 patients (50% male, median age 48 years, range 17–72 years), the underlying aetiology included idiopathic in five (41.6%), tuberculosis in four (33%), and malignancy in three patients (25%). Elective surgery was performed in nine patients. Median values of both central venous pressure and pulmonary capillary wedge pressure decreased markedly postoperatively (from 16.5 to 11.0 mmHg, p = 0.02; 20.0–15.0 mmHg, p = 0.01, respectively). There was no in-hospital mortality. Follow up ranged from three months to nine years (median three years). Five (41.6%) patients died during the follow-up period, and cumulative two-year survival was 55.6 ± 1.5%.

Conclusion

Pericardiectomy for ECP was effective, in terms of our early results, in patients unresponsive to medical therapy. Long-term survival depends on the underlying disease.

Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience

OBJECTIVES

Constrictive pericarditis is the result of a spectrum of primary cardiac and non-cardiac conditions. Few data exist on the preoperative risk specific to survival after pericardiectomy. This study was designed to compare the association of aetiology of constrictive pericarditis and other clinical variables, with long-term survival after total pericardiectomy.

METHODS

A total of 89 patients were studied, who underwent pericardiectomy for constrictive pericarditis at a single surgical centre between 1988 and 2012. Constrictive pericarditis was confirmed by the surgical report. Demographic, pre-, intra- and postoperative data and long-term outcome were investigated. Survival was assessed by the Kaplan-Meier method.

RESULTS

Aetiology of constrictive pericarditis was idiopathic in 49 patients (55%), prior cardiac surgery in 21 patients (23.6%), tuberculosis in 5 patients (5.6%), radiation treatment in 5 (5.6%), uraemia in 4 (4.5%), inflammation in 3 (3.5%) myocardial infarction in 2 (2.2%), and perioperative mortality was 7%. Seventy-five percent of patients were in New York Heart Association (NYHA) class III-IV, which status significantly improved in long-term survivors (95% in NYHA I-II). Idiopathic constrictive pericarditis had the best prognosis (5-year Kaplan-Meier survival: 81%) followed by post-surgical (50%) and post-radiation pericarditis (no survivors after 5 years). Tuberculosis, myocardial infarction and uraemia have survival rates comparable with idiopathic aetiology. In addition, preoperative NYHA class IV was associated with significantly lower long-term survival.

CONCLUSIONS

Long-term survival after pericardiectomy for constrictive pericarditis is related to underlying aetiology and overall clinical condition. The relatively good survival with idiopathic constrictive pericarditis emphasizes the safety of pericardiectomy in this subgroup.